F58

Fall Creek Rehabilitation and Healthcare Center

Grade F 58/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
3/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

126

Ownership

For profit - Limited Liability company

Total Fines

$48,555

Last Survey

N/A

14949 Mesa DR, Humble, TX 77396
2819024152

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.15h
LPN
1.10h
CNA
1.79h
Total
3.04h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

BULLPEN ONE, LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2015

10%

EDAWS INVESTMENT GROUP, LP

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Dec 2015

90%

BULLPEN FAMILY VENTURE, LP

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2015

REED, MICHAEL

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2015

REED, STACIE

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Dec 2015

THREADGILL, FORREST

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Oct 2020

THREADGILL, MORGAN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Oct 2020

THREADGILL, SHARLYN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Oct 2020

SUTER, RACHEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jun 2016

THREADGILL, SHARLYN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Oct 2020

CLEARLAKE HEALTHCARE REALTY, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince Oct 2020

COMPTON3 HOLDINGS, LLC

Organization5% OR GREATER MORTGAGE INTERESTSince Oct 2020

MARTEL HEALTHCARE MANAGEMENT LLC

Organization5% OR GREATER MORTGAGE INTERESTSince Oct 2020

THE SMITHERS MANAGEMENT TRUST

Organization5% OR GREATER MORTGAGE INTERESTSince Oct 2020

COMPTON, CHARLES

Individual5% OR GREATER MORTGAGE INTERESTSince Oct 2020

COMPTON, JAMES

Individual5% OR GREATER MORTGAGE INTERESTSince Oct 2020

COMPTON, KRIS

Individual5% OR GREATER MORTGAGE INTERESTSince Oct 2020

MARTEL, MICHAEL

Individual5% OR GREATER MORTGAGE INTERESTSince Oct 2020

Penalties & Fines (2)

$48,555total fines
DateTypeDescriptionAmount
Apr 13, 2025Fine$33,683
Feb 5, 2025Fine$14,872

Health Inspection Deficiencies (20)

July 8, 2025Health1 deficiency
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jul 14, 2025
May 30, 2025Health2 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Jun 2, 2025
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Jun 2, 2025
April 13, 2025Health3 deficiencies2 severe
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Apr 14, 2025
0580KImmediate jeopardy, Pattern

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Apr 14, 2025
0691KImmediate jeopardy, Pattern

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Apr 14, 2025
February 5, 2025Health2 deficiencies2 severe
0656JImmediate jeopardy, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 6, 2025
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 6, 2025
March 13, 2024Health3 deficiencies3 severe
0600KImmediate jeopardy, Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 15, 2024
0602KImmediate jeopardy, Pattern

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 21, 2023
0761KImmediate jeopardy, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Nov 21, 2023
March 7, 2024Health2 deficiencies
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 3, 2024
0692EMinimal harm, Pattern

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Apr 3, 2024
December 8, 2022Health3 deficiencies
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 14, 2022
0761EMinimal harm, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Dec 14, 2022
0814CNo harm, Widespread

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies

Corrected Dec 14, 2022
September 23, 2021Health4 deficiencies
0552EMinimal harm, Pattern

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Oct 21, 2021
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 21, 2021
0677EMinimal harm, Pattern

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 21, 2021
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 21, 2021

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Frequently Asked Questions

What is the CareGrader rating for Fall Creek Rehabilitation and Healthcare Center?

Fall Creek Rehabilitation and Healthcare Center in Humble, Texas has a CareGrader grade of F (Poor), with a composite score of 57.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Fall Creek Rehabilitation and Healthcare Center?

Fall Creek Rehabilitation and Healthcare Center has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Fall Creek Rehabilitation and Healthcare Center have?

Fall Creek Rehabilitation and Healthcare Center has 20 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Fall Creek Rehabilitation and Healthcare Center been fined?

Yes. Fall Creek Rehabilitation and Healthcare Center has $48,555 in total fines from CMS enforcement actions across 2 penalties.

How many beds does Fall Creek Rehabilitation and Healthcare Center have?

Fall Creek Rehabilitation and Healthcare Center has 126 certified beds with approximately 76 current residents (60% occupancy). The facility is located at 14949 Mesa DR, Humble, Texas 77396. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.